Technical Note

Hip Manipulation Under Anesthesia for Post-Hip

Arthroscopy Pericapsular Scarring: Indications and
Techniques
Natalie M. Gaio, M.D., Elizabeth H. G. Turner, M.D., and Andrea M. Spiker, M.D.

Abstract: Hip arthroscopy has become an increasingly common procedure with expanding indications over the last
several decades. With the increase in number of procedures performed a complication profile has emerged, although there
is yet to be a formal classification system for complications. The most cited complications include lateral femoral cutaneous
nerve neuropraxia, other sensory deficits, chondral or labral iatrogenic damage, superficial infection and deep vein
thrombosis. One complication that has not yet been well documented in the literature is pericapsular scarring/adhesions
resulting in decreased hip range of motion and function. If this complication is noted to persist after adequate impinge-
ment resection and a rigorous post-operative physical therapy regimen, the senior author has addressed this with a hip
manipulation under anesthesia. Therefore, this techniques paper aims to describe pericapsular scarring as a post hip-
arthroscopy condition which may cause pain and demonstrate our technique to address this diagnosis through hip
manipulation under anesthesia.

Introduction from 2007 to 2011.4,5 From 2011 to 2018, the incidence

T he use of hip arthroscopy has continued to grow
over the past decades, in part, due to expanding
indications, improved techniques and instrumentation
and increased exposure of residents and fellows.1
Common indications for hip arthroscopy include fem-
oroacetabular impingement syndrome (FAIS) from
underlying cam and/or pincer morphology and labral
pathology.2,3 The number of hip arthroscopic proced-
ures has been estimated to have increased more than
600% from 2005 to 2010, with an increase of 250%
From the Department of Orthopedic Surgery, University of Wiscon-
sindMadison, Madison, Wisconsin, U.S.A. (N.M.G., A.M.S.); and Depart-
ment of Orthopedic Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A.
(E.H.G.T.).
The authors report the following potential conflicts of interest or sources of
funding: A.M.S. reports consulting fees from Stryker, outside the submitted
work. Full ICMJE author disclosure forms are available for this article online,
as supplementary material.
Received November 19, 2022; revised manuscript received February 1,
2023; accepted February 14, 2023.
Address correspondence to Andrea M. Spiker, M.D., Department of Or-
thopedic Surgery, University of Wisconsin Madison, UW Health at The East
Madison Hospital, 4602 Eastpark Blvd, Madison, WI 53718, U.S.A. E-mail:
spiker@ortho.wisc.edu
Ó 2023 THE AUTHORS. Published by Elsevier Inc. on behalf of the
Arthroscopy Association of North America. This is an open access article under
the CC BY license (http://creativecommons.org/licenses/by/4.0/).
2212-6287/221517
https://doi.org/10.1016/j.eats.2023.02.036
of hip arthroscopy in patients with femoroacetabular
impingement and labral pathology increased by 85%.6
The most recent numbers do show that the exponen-
tial growth may be plateauing at a now continued high
rate.7 With an increasing number of hip arthroscopic
procedures performed comes an increase in the asso-
ciated complications. Although there is no universal
grading scheme for complications related to hip
arthroscopy surgery, the most commonly cited com-
plications include neuropraxia, iatrogenic labral or
chondral damage, inadequate resection resulting in
continued impingement versus overresection resulting
in instability, heterotopic ossification and less
commonly, damage to the vasculature of the femoral
head resulting in avascular necrosis.5 A recent large
prospective multicenter study cited an overall compli-
cation rate of 8.3%, with the most common complica-
tions noted to be lateral femoral cutaneous nerve
neuropraxia, other sensory deficits, chondral or labral
injury, superficial portal infection, deep vein throm-
bosis, heterotopic ossification, or femoral neck stress
fracture.8 Although these aforementioned complica-
tions have been previously documented in the litera-
ture, there is a paucity of information related to
postoperative pericapsular adhesions resulting in stiff-
ness of the hip after surgery, even in the setting of
adequate impingement resection. Therefore, this tech-
nical note aims to describe pericapsular scarring as a

Arthroscopy Techniques, Vol 12, No 6 (June), 2023: pp e983-e988 e983

e984 N. M. GAIO ET AL.
Fig 1. Demonstration of the butterfly position on the left side,
knee flexed and hip abducted which can reproduce anterior
hip pain, as indicated by the arrow, in diagnosis of peri-
capsular scarring postoperatively. Ideally, when evaluating
the patient in clinic, both feet should be simultaneously placed
in the butterfly position so that the pelvis does not rotate.
post-hip arthroscopy condition, which may cause pain
and demonstrate our technique to address this diag-
nosis through hip manipulation under anesthesia.
Fortunately, in our experience, when patients have
pain related to postoperative pericapsular scarring, they
have achieved resolution of pain with a manipulation
under anesthesia of the hip.
Surgical Technique
Indications and Diagnosis of Pericapsular Scarring
The hip is a complex multiaxial ball and socket joint
that attributes its stability to a combination of bony
anatomy, acetabular labrum, articular cartilage, liga-
mentous hip capsule, and surrounding musculature.5,9
The anatomy results in absolute limits to motion,
which have been found to be on the order of 120
flexion, 10 extension, 45 abduction, 25 adduction,
15 internal rotation, and 35 external rotation.9 A
normal gait pattern typically uses 40-50 of hip rota-
tion, 35 hip flexion and 10 hip extension.9 When
addressing the hip arthroscopically, there have been
two major compartments described.10 There is the
central compartment, which is composed of the lunate
cartilage, acetabular fossa, ligamentum teres, and the
loaded articular surface.10 The second compartment is
the peripheral compartment, which is composed of the
unloaded cartilage of the femoral head, the femoral
neck with medial, anterior, and lateral synovial folds
Table 1. Equipment Required
 Bag mask ventilation
 Traction Table*
* Stryker Pivot Guardian Distraction System with post or Smith and
Nephew Traction table with post (in order to pull steady, controlled
traction for just a couple seconds; whereas the senior author’s pref-
erence is to otherwise perform hip arthroscopy post-free).
(Weitbrecht’s ligaments), and the articular capsule,
which is divided into three distinct ligaments (iliofe-
moral ligament, ischiofemoral ligament, and femoral
arcuate ligament).10 When work is done in the pe-
ripheral compartment to address cam type impinge-
ment, it is our belief that pericapsular scarring can
occur. In the postoperative setting, this can result in
either a decreased range of motion and function or no
improvement in preoperative range of motion with
continued hip symptoms.
In evaluating patients with residual decreased range
of motion or function postoperatively, it is important to
take into consideration several different etiologies. First,
inadequate resection resulting in ongoing impingement
is a well-documented post-hip arthroscopy condition
that can account for continued anterior hip symptoms.5
Intraoperative evaluation, as well as radiographs,
arthroscopic images, and postoperative radiographs
should be scrutinized. It is the senior author’s practice
to take the hip through dynamic flexion and extension
at the time of the cam resection to ensure no ongoing
impingement exists, confirmed with fluoroscopy and
direct visualization with the arthroscope. Intraoperative
arthroscopic images and fluoroscopy images can
represent this dynamic assessment that took place.
Further imaging can be considered in the form of an
magnetic resonance image (MRI) arthrogram. An
arthrogram is favored over a nonarthrogram MRI in
patients who have had prior surgery. This may be
helpful to rule out capsular dehiscence or labral retear,
if suspected. However, if performed early after surgery
(within 6 months of hip arthroscopy), images may be
difficult to interpret and provide little value. Therefore,
if pericapsular scarring is favored to be the cause of loss
of motion, advanced imaging is not routinely obtained
in the early postoperative period.
In our experience, postoperative pericapsular scarring
presents as pain in the anterior hip, but patients tend to
describe it as “different” from their preoperative ante-
rior hip pain. Patients describe the pain as more su-
perficial. The positions at which it occurs can overlap
with classic impingement positions; namely, deep
flexion or flexion plus adduction and internal rotation
(FADIR). However, the “butterfly” positiondideally
with the soles of the feet together to level the pelvis,
knees flexed, and hips abducted, will also replicate the
pain, and the affected side will not abduct as far to the
 HIP MANIPULATION UNDER ANESTHESIA
Fig 2. Table used to document range of motion once the patient is sedated. It is important that an assistant hold the pelvis stable
during assessment of motion, as well as during the manipulation procedure, while another assistant writes the degrees of flexion
down. MUA, manipulation under anesthesia.
table. With this position, patients will note a replication
of the pain due to pericapsular scarring and will
describe motion that is more limited than the unaf-
fected side (Fig 1).
Our standard hip arthroscopy postoperative protocol
involves the initiation of physical therapy within 1-
5 days of surgery with our hip-specialized physical
Fig 3. The first maneuver of hip manipulation under anes-
thesia is gentle hip flexion. This is performed with the patient
in the supine position on the operative table. An assistant,
standing on the contralateral side, should hold the pelvis
stable by pushing down on the iliac crests. Flexion is per-
formed by flexing both the hip and knee of the affected side,
placing one hand on the ankle to promote flexion and one
hand on the knee for control as indicated by the arrow.
Flexion is performed in the neutral position (no adduction).
e985
therapists. The published protocol for our institution
can be found in Appendix A. Depending on the specific
intraoperative work performed, the rehabilitation pro-
tocol can vary; however, generally weight bearing is
progressed from 20% body weight with the use of
crutches to full weight bearing, as gait is normalized and
pain free over the course of the first 2-3 weeks post-
operatively. For the first 6 weeks, there are range of
motion restrictions; specifically no external rotation
beyond 30 and no hip hyperextension, with the goal of
protecting the labral and capsule repair during the early
postoperative period. At the 6-week mark, we
encourage stretching and emphasize strengthening. At
12 weeks, we reintroduce impact activity and progres-
sion of sports-specific activity. We believe it is important
that all patients participate and complete a rigorous
course of physical therapy before additional measures
are considered to address ongoing loss of motion.
However, if an adequate physical therapy regimen
has been performed without improvement, hip
manipulation under anesthesia is an option that we
discuss with patients.
Anesthesia for Manipulation
The post-hip arthroscopy hip manipulation procedure
occurs in the operating room. Patients have an IV
placed in the preoperative area for administration of IV
sedation. On the continuum of depth of sedation, these
cases are performed somewhere between deep sedation
and general anesthesia, most often favoring general
anesthesia, according to the American Society of An-
esthesiologists definition.11 This has typically been done
using a combination of midazolam, fentanyl, and pro-
pofol; although exact combinations may differ
depending on the anesthesia provider and the patient.
Bag mask ventilation is used as needed for respiratory
support (Table 1). The procedure itself takes less than
10 minutes per hip, so giving the anesthesia team
appropriate estimates of procedure length allow them
to titrate their sedation medications appropriately.
Patient Positioning and OR Setup
The patient is placed supine on a traction table with
bony prominences well padded. While the senior
e986 N. M. GAIO ET AL.
Fig 4. The second maneuver utilized in hip manipulation
focuses on external rotation of the affected hip with a fluid
motion between neutral hip flexion, while transitioning into
extension. An assistant is still holding the pelvis level. The hip
and knee are carefully extended in a controlled manner,
supporting the knee and lower leg.
author uses exclusively post-free traction for the hip
arthroscopy surgery, she does use a post to pull gentle
traction at the beginning of this procedure before
manipulating the hip (Table 1). Antibiotics are not
indicated in the absence of a planned incision and are,
therefore, not administered.
Manipulation Procedure
Premanipulation ranges of motion of both the oper-
ative and nonoperative hip are recorded (Fig 2). This
includes hip flexion, hip internal rotation at 90 , hip
external rotation at 90 , and hip abduction with
external rotation or the “butterfly” position (Fig 1),
measured as distance of the lateral thigh from the top of
the bed, measured in “fists” or centimeters. The hip is
then taken through a series of maneuvers (Video 1).
This includes gentle flexion (Fig 2), and then the
manipulation focuses mainly on externally rotating (Fig
3) and abducting (Fig 4) the hip in a fluid motion with
simultaneous hip circumduction, with the pelvis
Fig 5. As the leg is transitioned from flexion into extension,
focus is placed on abduction with external rotation of the
affected hip, while the pelvis is stabilized. This is done by
placing downward pressure on the knee and calf, as indicated
by the arrows, while maintaining the externally rotated po-
sition described in Fig 3.
stabilized by an assistant (Fig 5). Finally, the hip is
brought back into full extension (Fig 6). The hip is
taken through this series of maneuvers several times
using gentle consistent pressure (Table 2). Post-
manipulation range of motion measurements are taken
and recorded as in Figure 2.
In patients who are limited by both pain and range of
motion, we also offer hip manipulation to be performed
in conjunction with fluoroscopically guided intra-
articular injections. It is our goal to improve pain, so
that ongoing stretching and use of the hip can be per-
formed without deterrence by pain. Although most
often a concomitant intra-articular injection is not
needed, if the patient is at least 3 months out from
surgery and desires this be performed simultaneously,
the area is prepped in a sterile manner, and an 17 gauge
spinal needle is directed into the hip capsule under
fluoroscopic guidance. Intra-articular location is then
confirmed by injecting up to 1 mL of iohexol solution.
Once intra-articular location is confirmed, the hip is
 HIP MANIPULATION UNDER ANESTHESIA
Fig 6. Finally, the hip is brought back into full extension. This
is performed with one hand on the ankle to control extension
and the contralateral hand placed under the knee for support.
The full sequence of maneuvers is then repeated several times
using fluid movements and applying constant gentle pressure,
with an assistant helping to maintain a stable pelvis.
injected using a combination of 4 cc 10 mg/mL triam-
cinolone, 2 cc 1% lidocaine without epinephrine, and
2 cc 0.25% bupivacaine. The needle is then withdrawn,
and the injection site is covered with a small bandage.
Table 2. Pearls and Pitfalls
Pearls
 Pericapsular scarring pain is often elicited by the “butterfly” position
(Fig 1), and is more superficial in comparison to preoperative
impingement pain.
 Have an assistant present to hold the pelvis stable during
manipulation.
 Place gentle but consistent pressure on the leg during manipulation
maneuvers.
 Take the hip through manipulation maneuvers several times,
providing increased stretch each time.
 Focus on abduction, external rotation, circumduction as most post
operative pericapsular scarring occurs medially.
Pitfalls
 Avoid impingement positions, as, theoretically, the labrum could
retear in extreme impingement positions.
 Avoid using excessive force that could cause damage to previous
labral or capsular repair or musculature strain.
 While the senior author uses exclusively post-free traction for hip
arthroscopy, a post is used very briefly for this procedure to gently
pull the hip into traction before the manipulation procedure begins.
e987
Table 3. Advantages, Risks, and Limitations
Advantages
 Short duration of procedure
 No incision required, which could be counterproductive in forming
additional scar
Risks
 Involves the use of sedation and its established risks
Limitations
 Relies on patient participation in therapy
 Not as effective on intracapsular scarring compared to pericapsular
scarring
Postoperative Protocol
This manipulation under anesthesia procedure is
performed on an outpatient basis. The patient is
allowed to bear full weight, as tolerated, immediately
following the procedure, and there are no specific ac-
tivity restrictions. Physical therapy is prescribed and
encouraged postoperatively in order to maintain mo-
tion gained during the manipulation.
Discussion
Although the use of hip manipulation under anes-
thesia following hip arthroscopy has not been widely
documented in the literature, there are other in-
dications for which hip manipulation under anesthesia
has been performed. This dates back to the 1980s when
a study was published documenting joint manipulation
in head-injured patients to prevent heterotopic ossifi-
cation and maintain range of motion.12 In this study, 11
hips were included. Four had very little motion prior to
manipulation, and minimal improvement was seen.
However, of the remaining 7 there was an average of
52 increase in range of motion, and six patients had
greater than 85 gained.12 It was documented that the
manipulation involved hip flexion with internal and
external rotation and extension over the edge of the
table.12 A second study published more recently in
2016 was a systematic review, in which treatment op-
tions for adhesive capsulitis of the hip were reviewed,
including manipulation under anesthesia.13 In this
study, hip manipulation was noted to result in general
improvements in pain and range of motion. Therefore,
the technique of hip manipulation under anesthesia in
itself is not novel and has been documented to result in
improvements for pathology outside of post-hip
arthroscopy pericapsular adhesions. However, when
used in the context of post-hip arthroscopy, we suggest
differences in the previously documented manipulation
techniques. These differences include avoiding
impingement motions or positions and focusing on
stretching of the areas beneath the rectus femoris and
hip flexors, where scarring may have occurred in the
postoperative time period. This is especially targeted
through the “butterfly” position and dynamic hip
external rotation with simultaneous abduction,
e988 N. M. GAIO ET AL.
circumduction, and extension. This intervention is
particularly advantageous for targeting scar tissue, as it
does not require an additional incision, which would be
counterproductive to scar formation. This procedure is
also associated with minimal risk given the short
duration and minimal sedation necessary (Table 3).
However, it does still rely on patient participation in
therapy and is best for pericapsular, as opposed to
intracapsular scarring (Table 3). While hip arthroscopy
has been previously documented to result in increased
hip range of motion (15 -20 on average), it has been
noted that some patients still struggle to regain this
motion postoperatively despite adequate surgical tech-
nique and therapy.14 We propose that pericapsular
adhesions and scarring should be included in the dif-
ferential for patients who have residual lack of range of
motion after hip arthroscopy, and that when diagnosed,
hip manipulation under anesthesia can be a viable
treatment option.
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February 1, 2023.
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 HIP MANIPULATION UNDER ANESTHESIA e989

Appendix Table 1A. Hip Arthroscopy Postoperative Rehabilitation Protocol

Criteria Necessary to Advance to
Weeks Post-op Goals Precautions Next Phase
Phase 1 1-3  Protect surgical hip with limited  Avoid for six weeks:  Normal gait on level indoor
weight bearing  External rotation past 30 surfaces without pain nor as-
 Restore normal hip range of  Hip hyperextension sistive device
motion (ROM) within ROM  Abduction past 45  Functional ROM without pain
restrictions  May initially bear 20% body  Good leg control at low velocity
 Normalize gait weight, flat foot weight bearing, movement
 Restore leg control for all procedures
Phase 2 3-6  Wean off crutches  Postactivity soreness should  Normal gait on all surfaces
 Regain/Improve muscular resolve within 24 hours  Functional movements without
control  No ballistic or forced stretching unloading affected leg
 Single leg stance control  Caution with repetitive hip  10 single leg or split squats,
 Good control and no pain with flexion activities, such as balance testing
functional movements treadmill or Stairmaster
 More aggressive stretching be-
gins at 6 weeks post-op
Phase 3 6-20  Improve muscular strength and  Postactivity soreness should  Normal gait on all surfaces
endurance resolve within 24 hours  Dynamic neuromuscular
 Good control, no pain with  Caution with forceful hip control
work or sport specific activities, flexion activities, such as kick-  Pass progressive testing
including impact ing or sprinting
 Impact activity begins at
12 weeks post-op